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This case presentation details the evaluation and treatment of an 83-year-old gay man with depression, alcohol abuse, and the misuse of prescribed medications. The treating clinicians highlight multiple challenges of working with such patients, including split mental health treatment and coordination of care with medical providers. The paper further explores clinical issues related to aging, depression, substance use, and character pathology. The clinicians discuss transference and countertransference feelings that emerged during the treatment.

Naturally occurring leprosy has been demonstrated in wild nine-banded armadillos (Dasypus novemcinctus ). This suggests a possible mode of transmission of human leprosy in regions where armadillo contact is prevalent.Our purpose was to study the possible relationship between armadillo exposure and Hansen's disease.One hundred one patients (67 men, 34 women) with established Hansen's disease seen in the Hansen's Disease Clinic in Houston, Texas, were questioned about their exposure to armadillos. These patients were divided into two groups: Asian (n = 32) and non-Asian (n = 69).Seventy-one percent of the non-Asian patients surveyed reported either direct or indirect armadillo exposure. None of the Asian patients reported armadillo exposure (P.001). Of the non-Asian patients, 75.4% had lepromatous disease versus 50.0% of the Asian patients (P.001). The average age at diagnosis for the non-Asian group with Hansen's disease in this study was 51 versus 38 years for the Asian group (P.001).Although it is yet to be determined whether direct transmission from the armadillo to human occurs, it is likely based on the high incidence of armadillo exposure in non-Asian patients with Hansen's disease in our study population that this animal acts as a reservoir for human disease. However, the Asian patients reporting no known armadillo exposure likely obtained the disease from person-to-person contact in their respective countries of origin where Hansen's disease has a much higher prevalence.

Process flight simulation tools can help managers understand the dynamics of new processes and technologies before they are introduced. This article tells how these exploratory tools can be used for IS project management, simple modeling of the software process, and modeling the dynamics of the IS organization in transition.

The exact pathogenesis of chromoblastomycosis is unknown. Direct percutaneous inoculation, inhalation, and hematogenous dissemination have been implicated. We report a case of chromoblastomycosis that followed a well-defined episode of penetrating trauma. The causative organism, Fonsecaea pedrosi, was cultured from the patient's lesion and from the tree branch responsible for the trauma. This "natural" experiment supports the contention that one cause of chromoblastomycosis is traumatic cutaneous implantation of the fungus.

There are relatively few outcome studies of multidisciplinary chronic pain programs which have utilized no-treatment comparison groups. The present study compared a group of chronic pain patients (N = 42) treated in a comprehensive multidisciplinary pain program with a group of patients (N = 15) who were evaluated but not treated. Comparisons were made at evaluation and at a follow-up period averaging 11 months later. From evaluation to discharge, the treated group showed significant increases in physical functioning. From evaluation to long-term follow-up, both the treated and non-treated groups showed significant decreases in self-report pain ratings and interference with activities ratings. However, only the treated group showed a significant decrease in addictive medication use and increase in work functioning. The return-to-work rate for the treated group was 48% with an additional 28% of the patients being returned to vocational rehabilitation. None of the non-treated group returned to work or vocational rehabilitation. Results are discussed in terms of their support for the conclusion that comprehensive multidisciplinary pain programs produce marked subjective and functional changes.

Background Because of the adverse characteristics associated with heparin, direct antagonists of thrombin have been investigated as anticoagulants during percutaneous coronary interventions. However, the hematologic and clinical interactions between direct thrombin antagonists and inhibitors of platelet glycoprotein IIb-IIIa are incompletely explored. Methods Forty-two patients who underwent elective percutaneous coronary intervention were randomized to receive a bivalirudin 1.0 mg/kg bolus followed by a 4-hour infusion at 2.5 mg/kg/h; a bivalirudin 0.75 mg/kg bolus followed by a 4-hour infusion at 1.75 mg/kg; or a heparin 60 U/kg bolus. All the patients also received eptifibatide, given as 2 sequential boluses of 180 μg/kg followed by a 2 μg/kg/min infusion for 18 to 24 hours, and aspirin. Results After the bolus dose of the study drug, turbidimetric platelet aggregation in response to 5 μmol/L adenosine diphosphate increased in patients assigned to heparin but not those assigned to bivalirudin. After eptifibatide, platelet aggregation was eliminated in all 3 treatment groups. The effect of heparin and the effects of both bivalirudin regimens on the formation of thrombin antithrombin complexes and prothrombin fragment 1.2 were comparable. Neither agent affected the formation of platelet-monocyte complexes or expression of CD 63 lysosomal antigen. There were no major bleeding events, and a single non–Q-wave myocardial infarction (MI) occurred in a patient treated with bivalirudin. Conclusion These findings show the feasibility of combining the direct thrombin antagonist bivalirudin with a potent antagonist of platelet glycoprotein IIb-IIIa. Clinical trials are needed to assess the safety and efficacy of this combination. (Am Heart J 2002;143:585-93.)

Background: Panic disorder is a common and debilitating anxiety disorder which significantly disrupts the lives of patients and their family members. Recent epidemiological studies and analyses of data from clinical trials suggest that patients with panic disorder suffer significant work and social dysfunction. The authors hypothesized that this dysfunction could be characterized using both a well-validated, generalized scale of functioning and a specifically designed scale for assessing function in psychiatric patients and that these findings would correlate with symptomatology. Method: Fifty-six patients with panic disorder were characterized using the Sheehan Disability Scale, the Anxiety Sensitivity Index, and the Spielberger State Trait Anxiety Scale. Measures of health related quality of life from the Quality of Well Being Scale were compared with ratings for matched, historical, and population controls. Results: Patients with panic disorder lost 39 quality-adjusted days for each year that they lived with the disorder. This decrease in quality of life is similar to what is observed in patients with non-insulin dependent diabetes. Diminished quality of life is correlated with the number of panic attacks, state anxiety, and depressive symptoms. These patients also demonstrated significant dysfunction in Sheehan total disability and subscale scores, including work-related functioning. Conclusions: This study demonstrates that the specific disabilities inherent in panic disorder can be linked to declines in quality of life as measured by the Quality of Well Being Scale and by measures of work-related dysfunction. Such an association between disease specific measures and a generalized measure of health related quality of life may offer clinicians a new tool to understand panic disorder and to conceptualize it within the broader context of disease and disability.

JAVMA, Vol 223, No. 3, August 1, 2003 Fundamental economic change may seem to creep at a glacial pace. With the appropriate stimulus, though, a profession like veterinary medicine, which only a few years ago seemed to be in a chilling economic decline, can recover with surprising rapidity. Recent data about the rising income levels of veterinarians are signs that early action by leaders throughout the profession, along with the efforts of the National Commission on Veterinary Economic Issues (NCVEI), may be helping veterinarians master the management tools needed to practice successfully in the coming decade.

The T2-weighted spin-echo technique is currently the most frequently used magnetic resonance imaging (MRI) method to visualize acute myocardial infarction. However, image quality is often degraded by ghost artifacts from blood flow, and respiratory and cardiac contractile motion. To enhance the usefulness of this technique for detailed characterization of infarction, a velocity-compensated spin-echo pulse sequence was tested by imaging a flow phantom, 6 normal subjects and 17 patients with acute myocardial infarction. After preliminary studies were performed in 7 patients to determine optimal imaging parameters, a standardized imaging protocol was used in the next 10. The location of myocardial infarction identified by the electrocardiogram and coronary anatomy was correctly identified in 10 of 10 patients. Distribution of the injury within the left ventricle was clearly visualized, and showed that patients often had a mixture of transmural and nontransmural injury. Heterogenous distribution of signal intensity within the infarction suggested the presence of hemorrhage. Papillary muscle involvement was readily apparent. Signal intensity of the infarction (brightest segment) was increased by 89 +/- 31% compared with the mean of the remote segments. The myocardial/skeletal muscle ratio was significantly (p less than 0.001) increased for the infarction segments compared with that for remote myocardium, allowing quantitative analysis of segmental signal intensity. The MRI wall motion study obtained as part of this protocol demonstrated wall thickening in 58% of the infarction segments and in 6 of 10 patients. This finding suggested the presence of reversibly injured myocardium. In conclusion, the results demonstrate the potential of MRI for detailed tissue characterization after acute myocardial infarction.

In 80 patients admitted to a coronary care unit within 24 hours of chest pain thought to be due to acute myocardial infarction, routine diagnostic tests (electrocardiograms, total serum creatine kinase) as well as 99m technetium stannous pyrophosphate, TcPYP myocardial scintigraphy and serial serum radioimmunoassay determinations of the B subunit of creatine kinase (CK-B), were performed. None of these patients had clinical evidence of acute cerebral injury. A definite decision regarding the presence of acute myocardial infarction could be made in 77 patients on the basis of the results of routine diagnostic tests. The calculated sensitivity, specificity and predictive value of an elevated serum CK-B level in the recognition of acute myocardial infarction were each 100 per cent. Serial TcPYP scintigraphy was 97 per cent sensitive and 70 per cent specific, and had a predictive value of 96 per cent for the recognition of acute myocardial infarction. Both serum CK-B analysis and TcPYP myocardial scintigraphy were helpful in the recognition of infarct extension, and serial studies with both techniques suggested the presence of asymptomatic extension of infarction in several patients. The predictive value of each of these techniques for the recognition of a myocardial infarct suggests that both may be of diagnostic assistance to the physician in clinical settings in which the history, electrocardiogram or total serum creatine kinase are for some reason not interpretable. These techniques may also prove complementary in furthering the ability to assess the extent of acute myocardial damage and the course of its progression.

Basal cell carcinoma, the most common type of skin cancer, can be treated successfully by a variety of methods. The most commonly employed techniques are curettage with electrodesiccation, scalpel excision, Mohs' chemosurgery, cryosurgery, and radiation therapy, all of which have advantages and disadvantages. The primary care physician needs to be aware of available forms of therapy, problems with recurrent lesions, and the importance of adequate follow-up.

The inhibitory nature of yogurt against contaminating microorganisms has been studied extensively. Nevertheless, the factors responsible for the death of Salmonella typhimurium in yogurt have not been elucidated. An understanding of these factors is important for the determination of yogurt's safety to consumer health. Yogurt fermented for 18h at 42C had a stable environment with the following conditions: pH 3.85, oxidation-reduction potential −80mV, lactic acid concentration 158mM, and acetic acid concentration 3.7mM. Under these conditions, lactic acid was responsible for virtually all of yogurt's bactericidal activity against S. typhimurium at 37C. Die-off rates were observed when these conditions were reproduced artificially in milk (artificial milk yogurt) and when lactic acid was added back to 18-h yogurt from which acids were removed by passage of the whey through a Dowex 1 (C1 - ) anion exchange column (cationic yogurt). Factors that augmented lactic acid inhibition of S. typhimurium were low pH and low oxidation-reduction potential. The die-off rate of S. typhimurium was more rapid in yogurt whey (yogurt minus the casein fraction) than in whole yogurt, indicating that the casein fraction was partially able to protect Salmonella .

In the child mental health and child welfare fields, parent training has become a highly valued treatment and prevention service. As a national model to make parent-training services more available through public agencies, a program to train agency personnel to deliver a variety of parent-training services was developed. The program consisted of one-day conferences to showcase parent-training approaches and intensive workshops. Results of the first two training cycles were positive as graduates impacted thousands of persons but agency support was not uniform. Program modifications and expansions are indicated.

SUMMARY The diatom population structure of a salt marsh epiphytic community growing on Enteromorpha intestinalis was studied at one station throughout the summer. A total of 218 species or varieties were recognized. Six species— Fragilaria construens, Cocconeis scutellum, Cocconeis placentula, Achnanthes hauckiana varieties, Achnanthes pinnata, and Amphora coffeaeformis (var. acutiuscula)–dominated the Enteromorpha epiphytic community during the summer months and comprised ∼ 40% of the total populations. Melosira nummuloides, Opephora martyi, Synedra fasiculata var. tabulata, S. affinis, Navicula platyventris, and N. pavillardi were also very common species (13% of the total population). The distribution of many species in the community was seasonal. A series of differential media have been developed which are effective as tools for the isolation and nutritional characterization of the algae and bacteria from the community. Many diatom species can be recognized by their colony type or growth pattern on solidified media. A key and illustrated plates aid in identification. Changes in population structure of the community were reflected by changes in the nutritional patterns as judged by differences in the growth of diatoms and bacteria on the differential media tested. The nutritional requirements, selectivity, and rank order of media for individual species is given. Almost half of the colony types (32–33) grew on either unenriched seawater from the collection site or basal synthetic seawater. Erdschreiber was a poorer medium for the isolation of algae than seawater alone. Few algal colonies grew on either marine nutrient agar or trypticase soy agar. Nitrite inhibited algal growth. Media enriched with thiamine, biotin, or nitrate, phosphate, and B12 were stimulatory. Soil extract or an acetone extract of Enteromorpha tripled growth; a complex vitamin mixture, or glycerol, or mannitol, or an autoclaved extract of Enteromorpha doubled colony numbers. The greatest numbers of diatom types (43) and total colonies (655) were recovered on media enriched with acetone extract of Enteromorpha, suggesting a possible nutritional relationship between Enteromorpha and its epiphytes. The representativeness of the isolations from the natural community as a function of time was also considered. Concentrations of selected dissolved potential growth-stimulating nutrients were measured within and external to Enteromorpha communities. We conclude that the algal assemblage growing epiphytically on Enteromorpha intestinalis has a diverse auxotrophic profile which contributes to the productivity and stability within this important component of the epiphytic community and that much of the organic substrates used by individual species originate within and are recycled among the community members.

We determined how lactic acid inhibits growth of Salmonella typhimurium in yogurt. This inhibition was demonstrated by microscopic examination not to be due to bacteriolysis. Neither growth nor metabolic activity could be initiated after cells were washed in phosphate buffer and exposed to 1.5% lactic acid for 1 h at 37 degrees C, indicating that lactic acid inhibition is irreversible. The growth rate of S. typhimurium at 37 degrees C, was computed at various combinations of pH and lactic acid concentrations, and the intracellular conditions (pH and lactic acid concentration) at bacteriostasis subsequently were extrapolated. Cellular death resulted when these intracellular bacteriostatic conditions were surpassed. Thus, growing cells could be used indirectly to determine intracellular conditions at the time of death. Intracellular pH (pHi) and inhibition of the growth rate were unrelated. Also, bacteriostasis was observed when hydrochloric acid was used to lower the pHi of Salmonella to 5.5 whereas a bactericidal effect was observed when the pHi was lowered to 5.5 with lactic acid. The lactate anion, rather than the hydrogen ion, exerted the inhibitory effect against S. typhimurium. When the pHi became less than 5.3, inhibition was from the hydrogen ion concentration. Thus, lactic acid inhibition was a complex and variable mechanism in relationship with pHi Lactic acid entered the cell in the undissociated state. Once inside the cell, it dissociated because the pHi was higher than the external pH. The dissociated moiety accumulated because it could not leave the cell in this form consequently lowering the pHi. Thus, inhibition of S. typhimurium in yogurt is from the intracellular dissociated moiety of lactic acid.

The rates of mineralization of phenol, benzoate, benzylamine, p -nitrophenol, and di(2-ethylhexyl) phthalate added to lake water at concentrations ranging from a few picograms to nanograms per milliliter were directly proportional to chemical concentration. The rates were still linear at levels of p -nitrophenol per ml, but it was less than the predicted value at 1.53 pg of 2,4-dichlorophenoxyacetate per ml. Mineralization of 2,4-dichlorophenoxyacetate was not detected in samples of lake water containing 200 ng of the chemical per ml. The slope of a plot of the rate of phenol mineralization in samples of three lakes as a function of its initial concentration was lower at levels of 1 to 100 μg/ml than at higher concentrations. In lake water and sewage supplemented with 14 C-labeled benzoate or phenylacetate per ml, 95 to 99% of the radioactivity disappeared from solution, indicating that the microflora assimilated little or none of the carbon. The extent of mineralization of some compounds in samples of two lakes and sewage was least in the water with the lowest nutrient levels. No mineralization of 2,4-dichlorophenoxyacetate and the phthalate ester was observed in samples of an oligotrophic lake. These data suggest that mineralization of some chemicals at concentrations of

This study was designed to investigate the effectiveness of brief group therapy for underachievement, and remediation for deficiencies in basic skills, in reducing the attrition rate of nursing students. Students whose en tering California Test of Achievement scores or GPA's indicated risk of academic failure were interviewed: those with high scores (underachievers) received appropriate therapy, those with low scores and no motivational problems received remediation, and those with low scores plus motivational problems received both (20 hours total for each). Results indicated that a significant decrease in attrition rate can be attained by the foregoing tech niques. THE PROBLEM of student attrition, particu larly in nursing education, has been the subject of much concern and investigation. Investigators have recognized the phenomenon of the under achieve^ that is, a student who scores in the top quarter on ability/achievement measures but whose grades fall in the lower half of his class. The underachiever is, almost by definition, un likely to complete an academic program. It has become increasingly apparent that underachieve ment, rather than lack of ability, is the major cause of student attrition.

SYNOPSIS. The growth and reproduction of Allogromia laticollaris was studied. More schizozoites were generally produced in mixtures of food organisms than on single algal foods. In the presence of moderate numbers of bacteria, cultures with Phaeodactylum tricornutum, Chlorococcum sp., Nannochloris sp., and an unidentified chlorophyte (BL-1), added singly, were also highly productive. Schizogony was the dominant asexual form of reproduction. Binary fission and cytotomy also occurred in bacterized otherwise unfed controls. 35S and 32P are convenient labels for measuring growth of A. laticollaris when introduced into the system in the range of 1 × 104 - 1 × 105 dpm/ml (32P specific activity ∼ 2.03 MCi/g; 35S specific activity ∼ 95 μCi/g). Small allogromiids grew faster than did larger ones. By means of the Taylor series modification of the classical least-squares method, a continuous life-cycle representation was calculated for A. laticollaris for the conditions of the experiment. Four points of cell volume growth were maxima for reproduction: 1.0 × 107μ per organism for curve I; 2.2 × 107μ3 and 1.2 × 107μ3 for curve II; and 6.7 × 107μ3 for curve III.

General systems optimization principles predict that informationally encoded energy might be scavenged by efficient consumers and might play an important role in ecosystem trophic dynamics. Model microcosms were set up to study the informational processing potential of two microherbivores from the same habitat. The experimental design enabled parallel measurements of both information and calorimetric transfers in the same systems. The two experimental animals, Uronema marinum and Euplotes vannus , were grown separately in synchronous culture and were fed non-limiting quantities of various food organisms of equal calorific value but potentially different informational content for the consumers in order to detect potentially different efficiencies of utilization. Information utilization was reflected by cell cycle advancement and changes in rate of growth. The synchronously growing ciliates were also switched from one food species to another to study induction time for informational processing. Uronema was the ecologically more efficient of the two species tested. When logarithmically growing and fed certain strains of chlorophytes, its ecological efficiency approached 20%, while on diets of other chlorophyte species it dropped to only 6%. Ecological efficiency for Euplotes on various diets ranged from 2–12%. Induction time lags were found when switching both animals from one diet to another. The data clearly show that nutritional quality factors (molecular information) is part of energy flow in at least some food webs since the reproduction of the ciliates studied was neither a strict function of feeding rate nor strictly coupled with the calorific values of the food organisms themselves. A theoretical construct was designed to quantitatively evaluate the informational gain in food-consumer relationships. The difference between the energetic cost of growth for the consumer on the diet most informationally impoverished and other foods was chosen as a base to which all other foods could be compared. The difference between the energetic cost of growth on the base food and other food species can therefore be expressed in terms of energy saved per food organism processed per consumer generation. A new unit of information gain in food web transformations, the Cyberon, can be translated to other energy units through fundamental respiration relations. The theoretical energetic implications for resource distribution and utilization at the nanno, micro and meio levels of marine communities are discussed.

A sensitive and rapid method was developed to measure the mineralization of 14 C-labeled organic compounds at picogram-per-milliliter or lower levels in samples of natural waters and sewage. Mineralization was considered to be equivalent to the loss of radioactivity from solutions. From 93 to 98% of benzoate, benzylamine, aniline, phenol, and 2,4-dichlorophenoxyacetate at one or more concentrations below 300 ng/ml was mineralized in samples of lake waters and sewage, indicating little or no incorporation of carbon into microbial cells. Assimilation of 14 C by the cells mineralizing benzylamine in lake water was not detected. Mineralization in lake waters was linear with time for aniline at 5.7 pg to 500 ng/ml, benzylamine at 310 ng/ml, phenol at 102 fg to 10 mg/ml, 2,4-dichlorophenoxyacetate at 1.5 pg/ml, and di-(2-ethylhexyl) phthalate at 21 pg to 200 ng/ml, but it was exponential at several p -nitrophenol concentrations. The rate of mineralization of 50 and 500 ng of aniline per ml and 200 pg and 2.0 ng of the phthalate per ml increased with time in lake waters. The phthalate and 2,4-dichlorophenoxyacetate were mineralized in samples from a eutrophic but not an oligotrophic lake. Addition to eutrophic lake water of a benzoate-utilizing bacterium did not increase the rate of benzoate mineralization at 34 and 350 pg/ml but did so at 5 and 50 ng/ml. Glucose and phenol reduced the percentage of p -nitrophenol mineralized at p -nitrophenol concentrations of 200 ng/ml but not at 22.6 pg/ml and inhibited the rates of mineralization at both concentrations. These results show that the kinetics of mineralization, the capacity of the aquatic community to assimilate carbon from the substrate or the extent of assimilation, and the sensitivity of the mineralizing populations to organic compounds are different at trace levels than at higher concentrations of organic compounds.

A prospective, randomized trial was designed to assess the efficacy of intracoronary thrombolytic therapy with streptokinase (STK) in acute myocardial infarction. Sixty-four patients with acute myocardial infarction were randomized within 6 hours of onset of symptoms to 1 of 3 groups. Sixteen patients were treated by conventional means (control group). Nineteen patients underwent coronary arteriography and received corticosteroids and intracoronary and intravenous nitroglycerin (NTG group). Twenty-nine patients received management identical to that of the NTG group, with the addition of intracoronary STK therapy (STK group). Recanalization was demonstrated in 21 of 29 patients (72%) in the STK group. Global and regional ejection fraction (EF) was determined by radionuclide ventriculography before any intervention and 7 to 10 days later. No significant improvement in global EF was achieved in the control and NTG groups. In STK patients as a group, global EF did not increase significantly; however, in patients recanalized with STK, EF improved from 42 +/- 17% to 49 +/- 16% (p = 0.023). All groups showed wide variability of response. Improvement in global EF of more than 5% was noted in 44% of patients recanalized with STK. When subgrouped on the basis of initial global EF of 45% or less or more than 45%, only patients recanalized with STK with an initial EF of 45% or less had an improved global EF (from 30 +/- 10% to 42 +/- 10%, p = 0.015).(ABSTRACT TRUNCATED AT 250 WORDS)

42 freshman nursing students enrolled in a 3-yr. diploma program were tested on a battery of achievement/aptitude, demographic and personality measures. Product-moment correlations and multiple linear regression were utilized to assess relationships between criterion measures of success, academic failure and non-academic withdrawal with personal measures. Results may be used to develop an epidemiology of student attrition.

• The Jarisch-Herxheimer reaction is a self-limited, febrile episode that may occur following antibiotic therapy for syphilis. We report four cases of a heretofore unrecognized vesicular variant of the Jarisch-Herxheimer reaction. It is important to distinguish this phenomenon from an allergic drug eruption. (Arch Dermatol1989;125:77-81)